by Robert King | Dec 9, 2019 4:36pm
Major
bipartisan healthcare legislation to outlaw surprise medical bills will include
an arbitration backstop for out-of-network charges in a massive win for the
provider industry.
But
hospital and provider groups are already signaling that the concession isn’t
enough. Insurers are also livid with lawmakers for including the arbitration
proposal.
The
legislation would ban balance billing and use a benchmark rate for
out-of-network costs. However, unlike some other legislation tackling surprise
medical bills, the deal would include a “baseball-style” arbitration process
for bills greater than $750.
If a
bill goes to arbitration, the arbiter must consider context that includes
information on “training, education and experience of the provider, market
share of the parties and other extenuating factors,” an explainer on the
legislation said. A patient also is not obligated to pay a bill they receive 60
or more days after getting care.
The
legislation would also ban surprise medical bills for air ambulance rides. A
patient would only have to pay the in-network, cost-sharing amount for any
out-of-network rides.
“Air
ambulances are barred from sending patients ‘balance’ bills for more than the
in-network cost-sharing amount,” the explainer said.
If the
median in-network rate is more than $25,000, the air ambulance provider or
insurer can go to arbitration.
The
arbitration backstop is a major departure from legislation that passed out of
the Senate Committee on Health, Education, Labor and Pensions (HELP) earlier
this year. That bill only had a benchmark rate.
The
House Energy and Commerce Committee included an arbitration backstop, but it
only triggered if the out-of-network charge reaches $1,250.
Lawmakers
on both committees were enthusiastic about the deal.
“I do
not think it is possible to write a bill that has broader agreement than this
among Senate and House Democrats and Republicans on Americans’ number one
financial concern: what they pay out of their own pockets for healthcare,” said
Sen. Lamar Alexander, chairman of the Senate HELP Committee, in a statement
Sunday.
But
provider groups that have been fighting surprise billing efforts in Congress
weren’t as happy, despite the arbitration mechanism triggering at a lower
amount.
“Unless
this proposal is much improved over previous bills that rely on a benchmark
rate, it remains highly problematic and would jeopardize patient access to
hospital care, particularly in rural communities,” said Rick Pollack, president
and CEO of the American Hospital Association, in a statement.
The
national hospital-based physician group Envision Healthcare also blasted the
benchmark rate.
“While
this proposal is an improvement, it continues to use a benchmark that would not
apply to the majority of facility-based providers,” said Bob Kneeley, senior
vice president of government affairs at Envision. “Without an arbitration
mechanism that applies to a reasonable number of claims, the concerns
raised by the provider community will persist.”
On
the other hand, some insurer groups were opposed to the inclusion of
arbitration.
The
Coalition Against Surprise Medical Billing, a constellation of insurers and
business groups, said that an arbitration law in New York has been exploited by
providers and private equity firms to increase out-of-pocket costs.
“The
result of arbitration is that consumers, employers, unions and taxpayers
pay the price,” the coalition said in a statement. “Lawmakers should
continue to work to find real solutions that protect patients and save money
for taxpayers.”
But
some insurance groups were cautiously optimistic.
“We
believe real progress has been made and this agreement appears to protect
people from surprise medical bills, which has long been our goal,” said Justine
Handelman, senior vice president of the Office of Policy and Representation for
the Blue Cross Blue Shield Association.
The
massive bipartisan support bodes well for the chances of the legislation
getting out of Congress. The White House also voiced support for the deal on
Monday.
In
addition to surprise medical bills, the package would also:
·
Prevent “anti-tiering” and “anti-steering” clauses in
insurer-provider contracts. The clauses restrict the health plan from directing
or incentivizing providers to go with high-quality, lower-cost providers.
·
Stop “all-or-nothing” clauses in contracts between providers and
health plans which require insurance plans to contract with all providers in a
system or none of them, according to a summary of the bill.
·
Require health plans to have up-to-date directories on their
in-network providers.
·
Require group healthcare sponsors to receive a semiannual report
on costs, fees and rebates associated with pharmacy benefit manager contracts.
·
Incentivize healthcare entities to adopt strong cybersecurity
practices through conducting audits and fines related to HIPAA’s security rule.
·
Reauthorize funding for 1,400 community health centers.
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